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RESEARCH DAY
2018 University of Alberta
Department of Emergency Medicine
Faculty of Medicine and Dentistry
Tuesday, June 12th, 2018
Katz Group Centre for Pharmacy and Health
Research
6/12/2018
1
RESEARCH DAY AGENDA (KATZ 1-080)
08:00 – 08:30 Registration – Katz Atrium
08:40 – 08:50 Overview of the Day – Professor Christopher McCabe, Research
Director, Department of Emergency Medicine, Faculty of Medicine &
Dentistry, University of Alberta
08:50 – 09:00
Welcome Address – Dr. David Evans, Vice-Dean of Research, Faculty of
Medicine & Dentistry, University of Alberta
Moderator: Dr. Bill Sevcik
09:00 – 09:15 Young, C: Emergency department electrocardiogram interpretation: Clinical
impact of misreads and variables influencing misreads
09:15 – 09:30 Ali, S: iPad distraction during intravenous cannulation in the pediatric
emergency department: a randomized clinical trial
09:30 – 09:45 Douma, M: Describing out-of-hospital cardiac arrest to improve recognition:
an analysis of online cardiac arrest videos
09:45 – 10:00 Sivakumar, M: Physicians’ knowledge, attitudes, and practices regarding
opioid use in the pediatric emergency department
10:00 – 10:15 O’Brien, D: Patient factors associated with being offered a take-home
naloxone kit in the Royal Alexandra Hospital emergency department
10:15 – 10:30 Resident Research Summaries
10:30 – 10:50 Refreshments and Coffee – Katz Lower Foyer
View Posters
10:50 – 10:55 Visiting Speaker Introduction – Dr. Brian Rowe, Professor, Department
of Emergency Medicine, University of Alberta. Tier I Canada Research
Chair in Evidence-based Emergency Medicine
10:55 – 12:00 Keynote Lecture – Dr. Aaron Orkin, Clinical Public Health Fellow,
DLSPH, University of Toronto. Researcher, Schwartz/Reisman Emergency
Centre, Mount Sinai Hospital
12:00 – 13:00 Complimentary Lunch – Katz Lower Foyer
View Posters
6/12/2018
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Moderator: Dr. Christopher McCabe
13:00 – 13:15 Picard, C: A systematic review and meta-analysis of tourniquet devices for
speed of application, successful hemostasis and patient tolerance
13:15 – 13:30 Rajagopal, M: An eight year review of pediatric injuries due to falls from
windows and balconies
13:30 – 13:45 Hill, N: Conceptualizing ‘unnecessary care’ in emergency departments (ED):
Qualitative interviews with ED physicians and site chiefs
13:45 – 14:00 Klemmer, D: Improving clinical outcomes by utilizing a nurse practitioner
model in emergency department
14:00 – 14:15 Ma, W: A quality improvement project: Identifying and managing latent
safety threats through a zone wide emergency department in-situ multiple
discipline simulation program
14:15 – 14:30 Refreshments and Coffee – Katz Lower Foyer
View Posters
Moderator: Dr. Michael Bullard
14:30 – 14:45 Smith, K: Development of the inner city attitudinal assessment tool
(ICAAT) for learners across health care professions
14:45 – 15:00 Moghrabi, R: Interventions aimed at improvement in emergency department
related transitions in care for adult patients with atrial fibrillation and flutter:
a systematic review
15:00 – 15:15 Lam, N and Morch, K: Implementing a procedural sedation checklist as a
quality improvement initiative
15:15 – 15:30 Dymond, M: Insights from a tertiary care intraosseous insertion practice
improvement registry: a two year descriptive analysis
15:30 – 15:45 Resident Research Summaries
15:45 – 16:15 Awards and Closing Comments
6/12/2018
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08:30 – 16:30 Poster display (Katz atrium)
Poster 1: Schonnop, R: Development, implementation and evaluation of a curriculum
for healthcare students working at electronic dance music events
Poster 2: Pompa, N: A randomized crossover trial of conventional versus modified chest
compressions in a height-restricted aeromedical helicopter
Poster 3: Zhuo, R: Identifying enteropathogens in children with acute gastroenteritis
through enhanced detection: a prospective cohort study
Poster 4: O’Dochartaigh, D: Blood on board: the development of a prehospital blood
transfusion program in a Canadian helicopter emergency medical service
Poster 5: O’Dochartaigh, D: A follow-up examination of prefilled “code cart”
epinephrine syringes for direct administration of small doses using a syringe priming
technique
Poster 6: O’Dochartaigh, D: Ultrasound guided peripheral intravenous access in the
emergency department: a practice improvement registry
Poster 7: Holroyd, B: Content of clinical informatics in international training standards
for emergency medicine specialists
Poster 8: Ma, W: Creating a successful emergency department based sustainable
multidisciplinary simulation program across multiple sites
Poster 9: Douma, M: Proximal external aortic compression for life-threatening
abdominal-pelvic and junctional hemorrhage: an ultrasonographic study in adult
volunteers
Poster 10: Ali, S: Validation of the stoplight pain scale tool in the Canadian emergency
setting
Poster 11: Colmers-Gray, I: The revised METRIQ score: an international usability
analysis of a quality evaluation instrument for medical education blogs
Poster 12: Fletcher, C: Development and implementation of a workshop for advanced
care planning and goals of care conversations in the emergency department
Poster 13: Hayward, J: Predictors of admission in unscheduled return visits to the
emergency department
6/12/2018
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Visiting Speaker Lecture
Aaron Orkin MD, MSc, MPH, CCFP (EM), FRCPC Clinical Public Health Fellow, Dalla Lana School of Public Health, University of Toronto
Researcher, Schwartz/Reisman Emergency Medicine Institute, Sinai Health System
Emergency Physician, Schwartz/Reisman Emergency Centre, Mt. Sinai Hospital
“The SOONER Project: Combining design, simulation, and trial
methods to bring naloxone distribution into everyday practice”
Naloxone distribution might help to solve the opioid overdose crisis, but naloxone kits have not been
designed for distribution in emergency departments or other clinical settings. The Surviving Opioid
Overdose with Naloxone Education and Resuscitation (SOONER) Project combines design research and
overdose simulation with a randomized trial to invent a new naloxone kit and evaluate its educational
effectiveness. Dr. Orkin will explore the opioid crisis, the SOONER Project, and the opportunities for
innovation and discovery when we blend design with health research.
Tuesday, June 12, 2018 from 1100am to 1200pm
Allard Family Conference Room
1-080 Katz Building
This visit has been funded in part by the Walter Mackenzie Visiting Speaker Fund
6/12/2018
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Abstracts
Oral Presentations In order of presentation
EMERGENCY DEPARTMENT ELECTROCARDIOGRAM
INTERPRETATION: CLINICAL IMPACT OF MISREADS AND VARIABLES
INFLUENCING MISREADS
Young C, Norris C, Medves J, Rowe BH, Taylor D.
Departments of Medicine (Cardiology) and Emergency Medicine, University of Alberta,
Edmonton, Alberta.
INTRODUCTION: Electrocardiograms (ECGs) are a common investigation in
the emergency department (ED) and past studies have documented high proportions of
discordance between ED physicians and final cardiologist interpretations. Despite this,
few would have resulted in altered management and there are limited studies examining
factors influencing misreads. The purpose of this study was to quantify the percentage of
discordant abnormal ECG interpretations, and those that were clinically important,
performed by ED physicians compared to cardiologists and to identify which factors
predict discordance.
METHODS: Fourteen full time volunteer ED physicians at the University of
Alberta Hospital participated. For each shift randomized during the study, the ED
physician completed a standardized interpretation form that was entered into a RedCAP
database. Cardiologists independently interpreted the same ECG at a later date without
knowledge of the ED physician interpretation. Any interpretation identified as abnormal
by the cardiologist was then compared with the interpretation by the ED physician, and
discordance was noted. The abnormal ECGs were further stratified into clinically
significant ECGs.
RESULTS: From all shifts, 223 ECGs were obtained. Discordance was identified
in 2.7% for abnormal ECGs, and 1.8% were initially determined to be clinically
important ECGs. Based on a chart review of the discordant ECGs, it was determined that
the management would not have been changed in any. There were not enough discordant
interpretations to analyze predictor variables.
CONCLUSION: Similar to more recent literature, this study indicated a very low
proportion of discordance between ED physician and Cardiologist interpretation of ECG,
and no clinically important ECG misreads. These results suggest there is limited value in
funding cardiologists to re-interpret ECGs performed in the ED. In an era of scarce
resources and elimination of unnecessary testing, the funds used for ECG over-reads
could be reallocated to higher priority areas.
6/12/2018
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IPAD DISTRACTION DURING INTRAVENOUS CANNULATION IN THE
PEDIATRIC EMERGENCY DEPARTMENT: A RANDOMIZED CLINICAL
TRIAL
Ali S, Ma K, Dow N, Vandermeer B, Issawi A, Scott S, Beran T, Graham TAD, Curtis S,
Jou H, Hartling H.
Department of Pediatrics, University of Alberta, Edmonton, Alberta.
INTRODUCTION: Intravenous (IV) cannulation is commonly performed in
emergency departments (ED), causing substantial pain and distress. Distraction has been
shown to reduce child-reported pain. Our primary objective was to compare the reduction
of pain and distress using iPad distraction in addition to standard care, versus standard
care alone.
METHODS: This randomized clinical trial, conducted at the Stollery Children’s
Hospital ED, recruited children between ages 6 to 11 years requiring IV cannulation.
Pain, distress, and parental anxiety were measured using the Faces Pain Scale-Revised,
the Observed Scale of Behavioral Distress-Revised, and the State Trait Anxiety
Inventory, respectively.
RESULTS: 85 children were enrolled, with 42 receiving iPad distraction and 43
standard care, of which 40 (95%) and 35 (81%) children received topical anesthesia,
respectively (p=0.09). There were 40 girls (47.1%) with a mean age of 8.32 +/- 1.61
years. The pain scores during IV cannulation (p=0.35) and the pre-post change in pain
score (p=0.79) were not significantly different between the groups, nor were the observed
distress scores during IV cannulation (p=0.09), or the pre-post change in observed
distress (p=0.44). Children in both groups had greater total behavioral stress if it was
their first ED visit (p=0.01), had prior hospitalization experience (p=0.04) or were
admitted to hospital during this visit (p=0.007). A previous ED visit was predictive of a
greater increase in parental anxiety from baseline (p=0.02). When parents were asked
whether they would use the same methods to manage pain for their child, parents of the
iPad group were more likely to say yes than were parents of the standard care group
(p=0.03).
CONCLUSION: iPad distraction during IV cannulation was not found to
decrease pain or distress more than standard care alone, but parents preferred its use. The
effects of iPad distraction may have been over-shadowed by potent topical anesthetic
effect.
6/12/2018
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DESCRIBING OUT-OF-HOSPITAL CARDIAC ARREST TO IMPROVE
RECOGNITION: AN ANALYSIS OF ONLINE CARDIAC ARREST VIDEOS
Douma M1, Picard C, Yun Z.
1Royal Alexandra Hospital, Edmonton, Alberta. 1University College Dublin, Ireland.
INTRODUCTION: In many communities, half of out-of-hospital cardiac arrests
(OOHCA) go untreated prior to emergency personnel arrival. One barrier to bystander
response is lack of recognition. This study’s purpose is to describe OOHCA to improve
recognition and encourage bystander response.
METHODS: Searching was performed from August 3rd to January 20th, 2018, on
the 26 most popular and largest video-hosting and social media platforms. Cardiac arrest
related search terms in English and Chinese were employed. The inclusion criteria were:
i) videos be of medium to high definition (>360p and >10 frames per second), ii) cardiac
arrest could be confirmed from two sources, iii) the reviewers reached agreement about
the presence prodromal and post-arrest signs in the video, and iv) the arrest was non-
traumatic in nature. Each platform was searched until 100 consecutive unrelated videos
were returned.
RESULTS: Eight hundred and twenty-one videos were identified. One hundred
and sixty-five videos met inclusion criteria and underwent content analysis. Before arrest,
68 (41%) of victims exhibited prodromal signs: 34 (21%) had unsteady gait; 42 (26%)
touched their head or neck; and 33 (20%) hip-flexed or braced themselves on their thighs
prior to collapse. After collapse, 97 (59%) victims exhibited post-collapse signs such as
agonal breathing (71, 43%) or tonic posturing/convulsions (39, 24%). Lay-response fell
into six categories: 38 (28%) victims were shaken, 28 (17%) received chest
compression(s), 18 (11%) had their head held, 17 (10%) were unsuccessfully lifted to a
standing position, 9 (5%) had their legs raised and 5 (3%) had an AED applied.
CONCLUSION: Many OOHCA resemble seizure and exhibit agonal breathing.
Initial bystander response is often absent or is unlikely to be therapeutic. This information
could be used to inform first aid education and improve cardiac arrest recognition.
6/12/2018
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PHYSICIANS’ KNOWLEDGE, ATTITUDES, AND PRACTICES REGARDING
OPIOID USE IN THE PEDIATRIC EMERGENCY DEPARTMENT
Fowler M, Ali S, Gouin S, Drendel A, Poonai N, Yaskina M, Sivakumar M1, Jun E, Dong
K.
1Department of Pediatrics, University of Alberta, Edmonton, Alberta.
INTRODUCTION: Inadequate pain management in children is ubiquitous in the
emergency department (ED). As the current national opioid crisis has highlighted,
physicians are caught between balancing pain management and the unknown risk of long
term opioid dependence. This study aimed to describe pediatric emergency physicians’
(PEPs) willingness to prescribe opioids to children in the ED and at discharge.
METHODS: A unique survey tool was created using published methodology
guidelines. Information regarding practices, knowledge, attitudes, perceived barriers,
facilitators and demographics were collected. The survey was distributed to all physician
members of Pediatric Emergency Research Canada (PERC), using a modified Dillman’s
Tailored Design method, from October to December 2017.
RESULTS: The response rate was 56% (136/242); 54% (60/111) were female,
mean age was 43.5 years (+/- 8.7), and 54% (74/136) had pediatric emergency
subspecialty training. For moderate and severe MSK-I, intranasal fentanyl was the most
common opioid for first line pain management (34.6% (47/136) and 60.3% (82/136),
respectively). 74% (91/123) of PEPs reported that an opioid protocol would be helpful,
specifically for morphine, fentanyl, and hydromorphone. Using a 0-100 scale, physicians
minimally worried about physical dependence (13.1 +/-19.1), addiction (16.3 +/-19.5),
and diversion of opioids (33.3+/-26.5) when prescribing short-term opioids. They
reported that the current opioid crisis minimally influenced their willingness to prescribe
opioids (29.1 +/-25.9). Physicians reported rarely/never (64%; 83/129) completing a
screening risk assessment prior to prescribing opioids.
CONCLUSION: Intranasal fentanyl was the top opioid for all MSK-I pain
intensities. PEPs are minimally concerned regarding opioid dependence, addiction, and
the current opioid crisis when prescribing short-term opioids to children. There is an
urgent need for robust evidence regarding dependence and addiction risk for children
receiving short term opioids in order to create knowledge translation tools for ED
physicians. Opioid specific protocols in the ED would likely improve physician comfort
in responsible and adequate pain management for children.
6/12/2018
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PATIENT FACTORS ASSOCIATED WITH BEING OFFERED A TAKE-HOME
NALOXONE KIT IN THE ROYAL ALEXANDRA HOSPITAL EMERGENCY
DEPARTMENT
O’Brien D; Dabbs D, Dong K, Hyshka E.
Royal Alexandra Hospital, Edmonton Alberta.
INTRODUCTION: In 2016, Edmonton’s Royal Alexandra Hospital
implemented a Take-Home Naloxone (THN) program in the Emergency Department
(ED) to provide THN access to individuals at risk of opioid poisoning. We sought to
identify the extent to which THN is offered to patients who present to the ED with opioid
poisoning, and whether patient-level factors are associated with being offered THN.
METHODS: We retrospectively reviewed charts from all ED visits for opioid
poisoning between April 2016 and May 2017. Data on patient demographics, intoxicants,
prescriptions, and clinical details were abstracted. Bivariate and multivariate analyses
using generalized estimating equations with logit link were used to identify factors
associated with being offered THN.
RESULTS: 299 unique individuals made 344 ED visits for opioid overdose
during the study period, 2 of whom died in hospital. Among ED visits where the patient
survived, THN was offered 49% of the time. Multivariate analysis showed that factors
associated with being offered THN included male sex (Adjusted Odds Ratio (AOR) 1.86;
95% confidence interval 1.06, 3.28), low Glasgow Coma Scale score (3-8) (AOR 4.03;
95% CI 1.92, 8.48), and reporting an illegal opioid intoxicant (AOR 2.80; 95%
confidence interval 1.31, 5.98). Patients were less likely to be offered THN if they were
prescribed opioids (AOR 0.44; 95% CI 0.22, 0.85), or if they left the ED without
approval (AOR 0.29; 95% CI 0.14, 0.59).
CONCLUSION: In this real-world evaluation of an ED-based THN program,
half of patients visiting the ED for opioid poisoning were offered THN. Clinicians were
more likely to offer THN to certain patients, including males, patients without an opioid
prescription, and patients reporting an illegal opioid intoxicant, even after controlling for
overdose severity and whether ED discharge was approved. Further efforts are needed to
ensure THN is offered to all eligible patients at risk of opioid poisoning.
6/12/2018
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A SYSTEMATIC REVIEW AND META-ANALYSIS OF TOURNIQUET
DEVICES FOR SPEED OF APPLICATION, SUCCESSFUL HEMOSTASIS AND
PATIENT TOLERANCE.
Picard C1 & Douma MJ
1Misericordia Community Hospital Emergency Department, Edmonton, Alberta.
INTRODUCTION: To analyse published literature on commercial and
improvised tourniquets, for the following outcomes: lower-extremity arterial hemostasis,
application speed, and patient tolerance.
METHODS: Studies were limited to English. Non-human studies, case series,
and intra-operative applications were excluded. A systematic review of MEDLINE,
PubMed, Google Scholar, and the Cochrane Database from 1992 to Dec 2017 was
performed. Article citations were also assessed.
RESULTS: Twenty-one studies were included in this analysis, testing 28
tourniquet devices. The most popular devices for arterial hemostasis were the Combat
Application Tourniquet (662 applications), Special Operations Forces Tactical
Tourniquet (307 applications), blood pressure cuff (80 applications), rubber tubing (58
applications) and the Emergency and Military Tourniquet (52 applications). The blood
pressure cuff achieved the highest (weighted averages) rate of occlusion at 99% (95% CI
93 to 100) based on four studies of 80 applications. Followed by the Emergency and
Military Tourniquet which achieved 83% (95% CI 72 to 93), based on three studies of 52
applications (p < 0.01). The fastest device to apply, taking 17 seconds (95% CI 11 to 23),
was surgical tubing based on two studies totalling 30 applications. Next fastest was the
blood pressure cuff, requiring 20 seconds (95% CI 18 to 22), based on two studies
totalling 58 applications (p = 0.08). No single device could be the most tolerated, due to
heterogeneity of outcomes and small samples.
CONCLUSION: This is the first study to aggregate tourniquet device evidence.
An important finding is the lack of a standardized evaluation methodology for
tourniquets. The quality of evidence is of very low quality due to the small sample sizes,
lack of blinding, selective outcome reporting and inconsistency of results. Common
medical equipment appears to outperform commercial tourniquets for arterial hemostasis
and speed of application; however, they are some of the least studied tourniquet devices.
6/12/2018
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AN EIGHT YEAR REVIEW OF PEDIATRIC INJURIES DUE TO FALLS FROM
WINDOWS AND BALCONIES
Rajagopal M, Kundra M, Craig W, Ali S, Mabood N, Rankin T, Dow N.
Department of Pediatrics, University of Alberta, Edmonton, Alberta.
INTRODUCTION: Unintentional falls from heights such as windows and
balconies pose a serious health hazard to the pediatric population. There is currently
limited Canadian data describing the epidemiology of, and circumstances surrounding
such falls. This study aimed to describe the incidence, demographic patterns, injury
patterns and risk factors associated with pediatric falls from windows and balconies.
METHODS: This study employed both retrospective medical record review and
prospective data collection. Retrospectively, charts were reviewed from January 2009 to
December 2014, and prospectively, consenting families were enrolled from February
2015 to February 2017. Children 0-17 years of age, who presented to the Stollery
Children’s Hospital Emergency Department (ED) due to a fall from a window or balcony
were included.
RESULTS: A total of 102 children were included; 72/102 (70.6%) were enrolled
retrospectively and 30/102 (29.4%) prospectively. The median age was 4.46 years (IQR
2.83-6.83) with 65/102 (67.7%) being male. 89/102 (87.2%) fall cases were from
windows and 13/102 (12.8%) from balconies. The mean estimated height of fall was 4.36
meters (+/- 2.50) with (59/67) 88.1% of falls occurring at the child’s own home. Out of
the 26 prospectively enrolled children with window falls, 25 (96.2%) had screens, 5
(21.7%) had guards, and 7 (31.82%) had stops in place. 20/23 (90%) children were noted
to have climbed on furniture or other objects, leading to the fall. 31/102 (30.4%) children
were admitted, out of whom 15 (48.4%) required surgery. There were no fatalities.
CONCLUSION: The vast majority of fall cases occurred in children under the
age of 5 years and from a window. This mechanism of injury is associated with high
morbidity and need for surgical treatment. Installation of key safety features in windows
and balconies, and legislation to mandate this, may help minimize pediatric fall-related
injuries.
6/12/2018
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CONCEPTUALIZING ‘UNNECESSARY CARE’ IN EMERGENCY
DEPARTMENTS (ED): QUALITATIVE INTERVIEWS WITH ED PHYSICIANS
AND SITE CHIEFS
Hill N, Krebs L.D, Villa-Roel, C, Rowe, B.H.
Departments of Sociology and Emergency Medicine, University of Alberta, Edmonton,
Alberta.
INTRODUCTION: “Unnecessary care” (UC) is an increasingly commonly used
term in medicine. Previous survey research suggests that definitions of UC vary among
and within groups. This research explores how emergency physicians and administrators
understand the term “UC”.
METHODS: Site chiefs and emergency physicians in an Alberta region were
recruited through email and online surveys respectively for a qualitative study. One hour
one-on-one in-depth interviews explored understandings of unnecessary care within the
emergency department (ED) context. Interview transcripts underwent thematic analysis.
RESULTS: Five physicians and seven site chiefs completed interviews. Two key
themes emerged. First, interviewees conceptualized UC as inappropriate or non-urgent
presentations. This patient-centric view raised non-urgent ED presentations as a health
system problem with complex components, including: lack of public knowledge of
healthcare resources, shrinking comfort and scope of community providers and patient
willingness to utilize other resources. Despite concerns over non-urgent visits,
interviewees expressed that these patients still need to be assessed/managed. The second
conceptualization focused on over-investigation (and to lesser extent, treatment). This
physician-centric conceptualization identified issues around: variation in physician risk
tolerance, established decision rules with the allowable “miss rates”, patient expectation
for testing or physician feeling that the patient was owed something or that patient would
not accept their diagnosis/treatment without testing. Additionally, interviewees described
patient characteristics that may initiate more aggressive investigation. An overarching
concern about the connection between UC and wasted resources was identified.
Additionally, interviewees emphasized that patient conversations are outside the scope of
UC despite their possible implications for limited time resources.
CONCLUSION: A range of concepts surrounding UC in the ED were identified.
Further exploring nuances of these conceptualizations may inform and improve the
effectiveness of campaigns seeking to improve efficiency in practice and reduce
inappropriate care. Additionally, this work provides an impetus for developing clearer
concepts of care within the ED.
6/12/2018
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IMPROVED CLINICAL OUTCOMES BY UTILIZING A NURSE
PRACTITIONER MODEL IN EMERGENCY DEPARTMENT
Grubb S, Klemmer D, Sharif N, Sookram S, Zibell C.
Strathcona Community Hospital, Sherwood Park, Alberta.
INTRODUCTION: Prior to opening Strathcona Community Hospital (STCH)
site leadership were tasked to develop an innovative care model to improve patient safety
and quality of care delivered in the emergency department (ED) utilizing a nurse
practitioner (NP) model. They developed 3 pillars: collaboration, multidisciplinary
approach, and improved patient satisfaction and ensuring no patient gets lost to follow
up. NPs work in the STCH ED, NP Intravenous therapy (IVT) clinic, and the NP
Emergency Department Transition (EDT) Clinic in Ambulatory Care. In the ED, NPs
provide direct clinical care and indirect care -judicious review of DI and microbiology
reports and care coordination for patients at risk of returning to the ED or those who
would otherwise get lost to follow up. The EDT clinic is an innovative NP lead clinic
with the purpose of providing timely, high-quality follow up care for patients in seen
previously in the ED.
METHODS: Data for the service delivery indicators came from data repository
and manual data collection looking at these outcomes: timely DI/microbiology results
review in ED; free up physician time for direct care; decreased ED visits for non-urgent
issues; safe transitions in care and improved patient satisfaction with ED care.
Quantitative data from service delivery, patient and staff surveys were analyzed using
Microsoft Excel and SPSS 19.
RESULTS: From June 2016 to January 2017 ED NPs at STCH: reviewed 3000
positive microbiology reports, made 517 f/u calls to patients regarding these results, and
reviewed 3181 DI results (freeing up approximately 2hrs/day of ED physician time. ED
hours with NP coverage have decreased the number of patients who left without
treatment (LWT) by approximately 50%, and improved STCH ED wait times to be
among the lowest in the Edmonton Zone. IVT NPs monitored 5000+ patient visits. EDT
NPs completed 837 patient visits; 371 letters to family physicians (FPs); 215 referrals;
and connected 520 patients to a new FP. Patient satisfaction surveys show 88-90% of the
patients were satisfied with their care.
CONCLUSION: NPs are integral members of the provider team at STCH,
providing direct clinical care and several valuable follow up services for ED patients. The
EDT clinic provides urgent follow up for ED patients unable to get a timely appointment
with their FP or no access to FP, prevents unnecessary returns to ED, and aids to bridge
ED services to FPs or specialists. NPs are the common thread through all departments
within the innovative model at STCH, contributing to quality patient care and high
patient satisfaction.
6/12/2018
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A QUALITY IMPROVEMENT PROJECT: IDENTIFYING AND MANAGING
LATENT SAFETY THREATS THOUGH A ZONE WIDE EMERGENCY
DEPARTMENT IN-SITU MULTIDISCIPLINE SIMULATION PROGRAM
Ma W, Mews L, Chan M, Brown T, O’Dochartaigh D.
Alberta Health Services, University of Alberta, Edmonton, Alberta.
INTRODUCTION: High fidelity, multidisciplinary, in-situ simulation can detect
latent safety threats (LST) such as system deficiencies, equipment failures, or conditions
predisposing to medical errors. Not well reported is whether these LST are effectively
managed. Emergency departments (ED) in the Edmonton zone conducted simulations as
part of a quality improvement project to identify LST and subsequently manage them.
METHODS: In 2017, 18 simulation sessions were conducted. Following each, a
cross sectional survey based assessment tool was completed by participants to identify
LST. Findings were shared with site clinical nurse educators and managers, and a
mitigation plan made. Follow-up occurred to track progress. For reporting, LST were
grouped into themes and progress coded as either resolved, ongoing, or not managed.
RESULTS: A total 162 LST were identified. The most commonly identified
were: lack of staff training (34), resuscitation resource required (n 29), equipment not
immediately available (28), medication not immediately available (14), medication
needed (14), medication resource required (13), IT resource required (8), staff requiring
familiarization (9), IT issue (5), small equipment needed (5), lack of staff resource (5),
large equipment needed (4), equipment malfunction (3), environment cluttered (3), non-
appropriate resource removed (2). Site follow-up identified a total of 75 LST that where
resolved and 87 that required ongoing work to manage. No occurrences of not managed
LST were identified.
CONCLUSION: Simulation effectively identified LST, which appeared common
in all EDs studied. Creating a structured plan and follow up resolved many LST and all to
be effectively managed. In 2018 simulation will reassess if LST remain. Additionally
zone learnings will be shared provincially to assess if similar threats exist in EDs across
the province.
6/12/2018
15
DEVELOPMENT OF THE INNER CITY ATTITUDINAL ASSESSMENT TOOL
(ICAAT) FOR LEARNERS ACROSS HEALTH CARE PROFESSIONS
McKinney M, Smith KE1, Dong KA, Babenko O, Ross S, Kelly MA, Salvalaggio G,
1University of Alberta, Edmonton, Alberta.
INTRODUCTION: Many health care learners feel uncomfortable and
underprepared for professional interactions with inner city populations, and may hold
biases which affect the therapeutic relationship. Targeted educational programs in inner
city health play a role in improving learner attitudes and future provision of health care;
however, few tools exist to evaluate attitudinal competencies within these programs.
METHODS: Tool development consisted of four phases: 1) Item identification
and generation informed by a scoping review of the literature; 2) Item refinement
involving a two stage modified Delphi process with a national multidisciplinary team
(n=8), followed by evaluation of readability and face validity with a focus group of
medical and nursing students (n=13); 3) Pilot testing with a larger cohort of medical and
nursing students, evaluating potential response bias with the Marlowe-Crown social
desirability scale; and 4) Analysis of psychometric properties through factor analysis and
internal reliability with medical and nursing students.
RESULTS: 214 of 1452 undergraduate students (67.7% from medicine and
32.3% from nursing) completed a 36-item online version of the Inner City Attitudinal
Assessment Tool (ICAAT), with a response rate of 15%. The emerging tool consists of
24 items, within a three-factor model – affective, behavioural, and cognitive. Reliability
values using Cronbach alpha were 0.87, 0.82, and 0.82 respectively. The reliability of the
whole 24-item ICAAT was 0.90.
CONCLUSION: The Inner City Attitudinal Assessment Tool (ICAAT) is a novel
tool with evidence to support its use in assessing health care learners’ attitudes towards
caring for inner city populations. This tool has the potential to help guide curricula in
inner city health.
6/12/2018
16
INTERVENTIONS AIMED AT IMPROVEMENT IN EMERGENCY
DEPARTMENT RELATED TRANSITIONS IN CARE FOR ADULT PATIENTS
WITH ATRIAL FIBRILLATION AND FLUTTER: A SYSTEMATIC REVIEW.
Gilbertson J, Moghrabi R, Kirkland SW, Tate K, Sevcik W, Lam NT, Rowe BH, Villa-
Roel C
Departments of Emergency Medicine and Pediatrics, and Faculty of Nursing, University
of Alberta, Edmonton, Alberta.
INTRODUCTION: Transitions in care (TiC) interventions have been proposed to
improve outcomes for patients in emergency departments (ED). The objective of this
review was to examine the effectiveness of TiC interventions to improve outcomes for
adult patients presenting to ED with acute atrial fibrillation or flutter (AFF).
METHODS: A comprehensive search of eight databases and grey literature
sources was conducted to identify comparative studies assessing the effectiveness of
interventions to improve TiC for patients presenting to ED with acute AFF. Two
independent reviewers completed study selection, quality/fidelity assessment, and data
extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using
a random effects model. and heterogeneity was reported among studies using I-square (I2)
statistics.
RESULTS: From 744 citations, seven studies were included. Study quality ranged
from unclear to low for the three RCTs, moderate in three before-after (B/A) studies, and
high in the cohort study. Most interventions were set within-ED (n=5), including clinical
pathways and ED observation units. Post-ED interventions (n=2) included patient
education and general practitioner referral. Three studies reported a significant decrease in
overall hospital length of stay for AFF patients undergoing TiC interventions, however,
incomplete outcome reporting precluded meta-analysis. An increased conversion to normal
sinus rhythm was reported among patients receiving TiC interventions, this may be related
to increased use of electrical cardioversion within the RCTs (RR=2.16; 95% CI: 1.42,
3.30), B/A studies (RR=2.69, 95% CI: 2.17, 3.33), and cohort study (RR=1.39; 95% CI:
1.24, 1.56).
CONCLUSION: Within-ED TiC interventions may reduce hospital LoS and
increase use of electrical cardioversion. However, no clear recommendations can be
generated from this systematic review and more efforts are required to improve TiC for
patients presenting to ED with AFF.
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17
IMPLEMENTING A PROCEDURAL SEDATION CHECKLIST AS A QUALITY
IMPROVEMENT INITIATIVE
Colmers-Gray I1, Lam N1, Mallia A1, Morch K1, Schonnop R1, Skoblenick K1,
Desrochers C, Hayward J, Hegstrom A, Chang E, Hanson A.
1Department of Emergency Medicine, University of Alberta, Edmonton, Alberta.
INTRODUCTION: Procedural sedations are a common procedure in the
emergency department (ED). Though frequently performed, sedations carry a potential
risk of harm. Surgeons and anesthetists have implemented pre-procedure time-outs with
checklists prior to commencing an operation, in attempts to mitigate procedure-related
risks. Our quality improvement (QI) initiative sought to implement a similar checklist for
procedural sedations performed in the ED.
METHODS: A one-page procedural sedation checklist was developed based on a
literature review and in consultation with relevant health professionals (respiratory
therapists [RTs], MDs). The checklist was completed by RTs at the Royal Alexandra
Hospital ED over a two-month period. Completed checklists were collected
anonymously. Data was summarized for further review, revision, and possible re-
implementation of this QI initiative.
RESULTS: 108 checklists were completed during the QI period. Checklist
section completions rates were 96% for pre-sedation preparation, 99% for equipment, and
85% for the MD timeout. Missing equipment was identified in 13% of checklists. One
case identified a number of potential hazards before initiating procedural sedation.
Overall satisfaction for the checklist was 66% for physicians, 59% for RTs and 55% for
nurses. Feedback was provided on 52% of checklists. Overall satisfaction for the
checklist was variable, though participants found it user friendly.
CONCLUSION: Implementation of a multidisciplinary procedural sedation
checklist over a two-month period was well completed and helped identify missing
equipment prior to sedation. The checklist allowed critical preparatory components of
procedural sedation to be verbalized. Future areas of research include improving the
checklist based on feedback received, and incorporating the checklist within established
ED protocols
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INSIGHTS FROM A TERTIARY CARE INTRAOSSEOUS INSERTION
PRACTICE IMPROVEMENT REGISTRY: A TWO-YEAR DESCRIPTIVE
ANALYSIS
Dymond, M., O’Dochartaigh, D, Douma, M.
Alberta Health Services, Edmonton, Alberta.
INTRODUCTION: Resuscitation guidelines suggest initiating intraosseous
access when intravenous access is not readily attainable. Few practice improvement
registries exist describing patient and clinician factors associated with intraosseous
insertion. This study reports on the creation of an emergency nurse-educator lead registry
that tracked intraosseous insertions so successes, failures, and adherence to standards
could be assessed.
METHODS: Emergency nurses assigned to resuscitation areas of the tertiary
emergency department completed an education module on intraosseous insertion and
maintenance. A tracking form was completed whenever intraosseous access was
attempted. The emergency department clinical nurse educator collected and collated the
tracking forms. A second researcher checked data abstraction accuracy.
RESULTS: Over two years, 17 pediatric patients (receiving 23 intraosseous
insertions) and 35 adult patients (receiving 40 intraosseous insertions) had forms
returned. Prior to an intraosseous attempt, the average number of intravenous attempts for
pediatric and adult patients were 4 [range 0-10], and 2 [range 0-5] respectively.
Successful pediatric intraosseous insertion rate was 6/15 (40%) for physicians, and 6/7
(86%) for emergency nurses. The leading cause of failed insertions was selecting a needle
that was too short, either not reaching the intramedullary canal or quickly becoming
dislodged. For adult patients intraosseous insertion success rates for physicians were
13/14 (93%) and 18/20 (90%) for emergency nurses. Data was not gathered on specific
physician level of training (i.e. residents or attending physicians), though this was added
for ongoing data collection. The most common destination for all patents were critical
care units.
CONCLUSION: Despite standard limitations of self-reported registry data, the
implementation of an intraosseous registry identified opportunities to improve clinical
practice through continued educational programming focused on the clinical threshold for
intraosseous use in pediatric patients and the appropriate selection of intraosseous
cannula.
6/12/2018
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Poster Presentations
DEVELOPMENT, IMPLEMENTATION AND EVALUATION OF A
CURRICULUM FOR HEALTHCARE STUDENTS WORKING AT
ELECTRONIC DANCE MUSIC EVENTS
R. Schonnop & D. Ha
University of Alberta, Department of Emergency Medicine, Edmonton, AB
INTRODUCTION: Mass Gathering Medicine (MGM) is a growing field within
emergency medicine (EM) and providing care at electronic dance music events (EDMEs)
is an increasingly popular activity with MGM groups. Often, health care students are
allowed to participate. However, there is a lack of documented curricula to train junior
learners in providing medical care at these events. To address this, we developed and
initiated an interprofessional, simulation-based workshop for University of Alberta health
care students interested in working at EDMEs.
METHODS: We used Kerns’ six-step approach to develop the workshops. Our
MGM Interest Group identified a need for educational sessions in toxicology case
management at EDMEs. A subsequent literature review revealed a paucity of pre-existing
curricula on this topic for MGM learners. We created goals and objectives for the
workshops, reflecting the knowledge, skills and attitudinal competencies required to
provide appropriate medical care at these events. The workshops were implemented and
evaluated in November 2016 and 2017.
RESULTS: A total of 44 medical and nursing students attended the workshops.
An EM resident and staff physician, both with prior experience working at EDMEs, led
each session. Each workshop began with a short didactic lecture followed by two hours
of case-based training using two standardized patients and a high fidelity simulator.
Topics were chosen based on previously published articles describing medical cases seen
at EDMEs. The simulation replicated the actual space, noise and equipment available at
the medical tents at these events. Two interprofessional learner groups took turns
managing a different set of 3 patients: Set 1-opioid overdose (OD), alcohol/vomiting,
sympathomimetic OD; Set 2-opioid OD not responsive to naloxone,
anticholinergic/seizure, OD with hyperthermia. Initial assessment, medical management
and team communication skills were emphasized. Debriefing was provided to learners
immediately after each set of cases. After each workshop, the learners completed
evaluation forms utilizing both Likert scale and open-ended responses. Overall, students
were extremely complimentary about the workshop structure, content and communication
skills teaching. They were especially appreciative of the opportunity to participate in their
first interprofessional team experience.
CONCLUSION: To address local needs, a well-received simulation-based
workshop was created to train students in toxicology case management at EDMEs. Future
work will include using this workshop in a “just-in-time” fashion before upcoming
6/12/2018
20
EDMEs and documenting students’ actual use of skills taught (Kirkpatrick level 3). The
workshop will also be further modified to implement more detailed interprofessional
objectives and can provide a venue for EM residents to practice teaching
interprofessional education competencies as part of their CanMEDS Scholar role.
6/12/2018
21
A RANDOMIZED CROSSOVER TRIAL OF CONVENTIONAL VERSUS
MODIFIED CHEST COMPRESSIONS IN A HEIGHT-RESTRICTED
AEROMEDICAL HELICOPTER
Pompa N1, ODochartaigh D2, Mackenzie M2, Douma MJ2.
1Department of Emergency Medicine, University of Alberta, Edmonton, Alberta. 2Alberta Health Services, Edmonton, Alberta.
INTRODUCTION: Aircraft are used world-wide to transfer patients to definitive
care. Low ceiling height can negatively affect chest compression (CC) performance. This
study compares CC techniques in a height-restricted aeromedical helicopter.
METHODS: Eighteen clinicians were randomized to two minutes of
conventional or modified CCs, then crossed-over. An Airbus BK117 helicopter with
56cm of space between the manikin and ceiling was used. The modified technique used a
forearm/elbow instead of overlapping hands. CC quality was assessed with a
SkillReporting Laerdal Resusci-Anne manikin. Quality variables were: the number of
CC, CC rate, depth and stroke length, release, land marking, and overall quality score.
Participant feedback was collected using the Borg Scale of Perceived Exertion, and CC
difficulty using a zero-to-ten scale. Furthermore, we solicited open-ended descriptive
written responses as well. A sample size calculation using pilot data indicated 16
participants would be required.
RESULTS: The mean stroke length was 43mm for conventional CC versus
49mm using the modified method (p < 0.05). The average overall quality score was 63%
for conventional CCs versus 79% for the modified CCs (p = 0.04). On average, the
modified CC method increased compression depth by 5mm (95% CI 4.3 to 5.7), the
proportion of compressions at the correct depth by 17% (95% CI 7.55 to 26.45) and
improved the overall quality score by 6% (95% CI 2.02 to 9.98). The modified method
resulted in statistically significant reductions in physical exertion and difficulty (p <
0.001). Qualitative feedback described modified CCs as easier and more sustainable.
CONCLUSION: In a height-restricted aeromedical helicopter, CC stroke length
and overall quality is improved using the modified method. In settings where the
compressor is affected by reduced overhead working height, the modified method of CC
may be an advisable alternative.
6/12/2018
22
IDENTIFYING ENTEROPATHOGENS IN CHILDREN WITH ACUTE
GASTROENTERITIS THROUGH ENHANCED DETECTION: A
PROSPECTIVE COHORT STUDY
Ran Zhuo1, Brendon D Parsons1, Bonita E Lee2, Linda Chui1.3, Stephen B Freedman4,
Samina Ali5, Karen Lowerison6, Xiao-Li Pang1,3 on behalf of the APPETITE Team
1Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton,
Alberta. 2Department of Pediatrics, University of Alberta, Edmonton, Alberta. 3Provincial Laboratory for Public Health (ProvLab, Alberta Health Services), Edmonton,
Alberta. 4Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s
Hospital and Alberta Children’s Hospital Research Institute, University of Calgary,
Calgary, Alberta. 5Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children’s
Health Research Institute, University of Alberta, Edmonton, Alberta. 6Cumming School of Medicine, University of Calgary, Calgary, Alberta.
INTRODUCTION: Acute gastroenteritis (AGE) is a common childhood
infection. While nearly 2 million children are brought to emergency department (ED)
annually in the US due to vomiting and/or diarrhea, it is estimated that it represents just
10% of affected individuals. Moreover, because collection of stool is burdensome and
cannot be performed in patients with isolated vomiting, sample submission rates are low.
Therefore, current pathogen-specific disease burden of AGE is likely underestimated.
The Alberta Provincial Pediatric EnTeric Infection Team (APPETITE) study is a
prospective province-wide study capable of estimating the relative distribution of
enteropathogens causing diarrhea and/or vomiting in Albertan children.
METHODS: Children less than 18 years of age with AGE and asymptomatic
controls were recruited through two pediatric EDs, a telephone health advice service:
Health Link Alberta (HLA) and a public health clinic. Rectal swabs and stool samples
were collected and tested for 5 viruses, 9 bacteria and 3 parasites using enteric bacteria
culture assays, an in-house gastroenteritis virus panel RT-qPCR and the commercially
available Luminex xTAG Gastroenteritis Pathogen Panel.
RESULTS: From Dec 2014 to Jan 2018, 2,427 children with AGE were enrolled
at the two EDs; 647 sick children were enrolled via HLA and 1,434 children were
enrolled as asymptomatic controls. 72.9% (n=2,199) of the 3,018 symptomatic patients
tested positive for ≥ 1 enteropathogen. Norovirus was the most commonly detected
pathogen (n=807, 26.7%), followed by adenovirus (n=563, 18.7%) and rotavirus (n=507,
16.8%). Clostridium difficile was detected in 14.4% (n=436) of symptomatic children and
in 11.6% (n=166) of the control individuals. Sapovirus (n=297, 9.8%) and astrovirus
(n=106, 3.5%) were less prevalent. Excluding C. difficile, 5.9% (n=176) patients were
infected by a bacterial pathogen and 0.5% (n=16) by a parasitic pathogen. Although 38%
(n=547) of the 1,434 asymptomatic children tested positive for ≥ 1 pathogen, 11.2%
(n=161) tested positive for rotavirus shortly following rotavirus vaccine administration.
6/12/2018
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CONCLUSIONS: This study allows us to understand the relative proportional
etiologies of enteropathogens in children with AGE.
6/12/2018
24
BLOOD ON BOARD: THE DEVELOPMENT OF A PREHOSPITAL BLOOD
TRANSFUSION PROGRAM IN A CANADIAN HELICOPTER EMERGENCY
MEDICAL SERVICE
Krook C, O’Dochartaigh D, McKay D, vanWerkhoven G, Painter S, Piggott Z, Deedo R,
Nesdoly D, Armstrong JN, Martin D.
Shock Trauma Air Rescue Society; Alberta Health Services, Edmonton, Alberta.
INTRODUCTION: Prehospital blood transfusion has been adopted by many
civilian HEMS agencies and early outcomes are positive. Shock Trauma Air Rescue
Society operates in Western Canada and started a blood on board process in 2013 in
Regina that has expanded to all bases. Two units of O negative packed red blood cells are
carried on every mission. We describe the processes and standard work ensuring safe
storage, administration, and stewardship of this important resource.
METHODS: The packed red blood cells are stored in an inexpensive, reusable
temperature controlled cooler at 1 - 6°C. Close collaboration with local transfusion
services and adherence to Canadian transfusion standards contributes to safety and
sustainability.
RESULTS: From October 1st 2013 to October 10th 2017 the Shock Trauma Air
Rescue Society administered blood to 431 patients. Blood on board was utilized in 62.9%
of cases. A total of 463 blood box units were administered and the majority of patients
(69.0%) received both units. The majority of patients were male (68.2%). Trauma was
the most common diagnosis (74.1%). The median age was 44 years old with 32 (11.7%)
pediatric patients (age less than eighteen). Of all patients, 241 (88.0%) survived to
hospital arrival. There was variation in frequency of blood box use between bases from
1.8 uses per 100 patients transported (Regina, Saskatchewan) to 7.0 uses per 100 patients
(Winnipeg, Manitoba). Blood used in Calgary, Alberta was 100% traceable and only
0.97% of total units dispensed were wasted. All wasted units were due to temperature out
of range and all events occurred within the first year. The vast majority of unused units
were returned to circulation.
CONCLUSION: We describe the process to set up and monitor a prehospital
blood transfusion program. Our standard work and stewardship processes minimize
wastage of blood while keeping it readily available for our critically ill and injured
patients.
6/12/2018
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A FOLLOW-UP EXAMINATION OF PREFILLED “CODE CART”
EPINEPHRINE SYRINGES FOR DIRECT ADMINISTRATION OF SMALL
DOSES USING A SYRINGE PRIMING TECHNIQUE
O’Dochartaigh D, Brindley P, Douma MJ
Alberta Health Services, Edmonton, Alberta.
INTRODUCTION: The use of prefilled syringes to administer epinephrine is
common. While vigorously supported by the manufacturer, the accuracy of delivering
small doses of epinephrine from 10 ml prefilled syringes has been questioned,
particularly when delivering lower volumes (0.5 to 3 millilitres (ml)). We performed an
in-vitro simulation trial, to assess the actual versus assumed volume of prefilled
epinephrine syringes to deliver volumes of 0.5 to 3 ml.
METHODS: We examined prefilled epinephrine syringes containing 100ug/ml
or 1mg in 10ml. Our goal was to determine expelled volume when the plunger was
depressed to target doses/volumes: 50ug/0.5ml, 100ug/1ml, 150ug/1.5ml, 200ug/2ml, and
300ug/3ml. Also total prefilled syringe volume was assessed. For each trial the
participant performed a technique of syringe priming and delivery of the desired dose that
mirrored everyday clinical practice. Participants were blinded to their results and two
researches confirmed delivered volumes. To assess the accuracy of smaller syringes, tests
were repeated with a 1ml and 3 ml syringe to first transfer the desired dose into.
RESULTS: The mean total volume of 10 prefilled syringes was 10.8mL (95% CI
10.66-10.94). We conducted 193 separate tests with the preload syringe and 152 separate
tests with the 1ml and 3 ml syringes. For the preload syringe, for all target volumes the
mean volume delivered was within 2% of the target and 95% were 3%. However,
minimum and maximum results deviated greatest for the 0.5ml and 1ml target volumes
(up to 24% and 13% respectively). For the 1ml and 3 ml syringes tests, results were
similar between syringe sizes. The mean volume delivered and the 95% were within 1%
of all target volumes. Minimum and maximum tests deviated no more than 6% for the
0.5ml volume and between 1.3% and 3% for all other target volumes
CONCLUSIONS: To increase accuracy, the volume of a prefilled syringe should
be zeroed prior to administration. For administering smaller volumes, and especially
volumes less than one ml, a smaller syringe should be considered.
6/12/2018
26
ULTRASOUND GUIDED PERIPHERAL INTRAVENOUS ACCESS IN THE
EMERGENCY DEPARMTENT: A PRACTICE IMPROVEMENT REGISTRY
O’Dochartaigh D, Douma MJ
Alberta Health Services Edmonton, Alberta.
INTRODUCTION: Ultrasound-guided peripheral intravenous catheter (UGIVC)
placement fills a gap in patient care: when peripheral IV access is assessed to be difficult
with traditional access methods of vein visualization and palpation, and intraosseous and
central venous access are not indicated. There is high quality evidence to support UGIVC
placement by nurses. At the University of Alberta emergency department (ED) a
standardized specialized clinical competency was created which included didactic
learning, in person simulation, and three successful mentored starts. Data was then
collected after UGIVC attempts to monitor the implementation of the program and assess
for quality improvement opportunities.
METHODS: Emergency nurses and paramedics that had completed the training
were asked to complete a tracking form whenever an UGIVC was attempted. An ED
paramedic entered the tracking forms into a database and a researcher checked data
abstraction accuracy.
RESULTS: Over ten months of data collection 12 pediatric patients and 55 adult
patients had forms returned. Prior to an UGIVC the average number of intravenous
attempts for all patients were 4.1 [range 0-12]. The overall successful insertion rate was
62/67 (93%). First attempt success was 47/67 (70%) second attempt 17/67 (24%), and
third attempt 3/67 (4%). Failure to gain UGIVC access occurred in 5/67 (7%) of cases.
Complications were 6/67 (9%) and reported as “insertion not successful” (n 4) and
“patient movement caused line to be lost” (n 2). Challengers or opportunities to improve
practice were reported under three areas: technique (such as improve tip tracking to avoid
back walling, improve patient positing, or use an extra person to assist); patient factors
(challenging site selection such as vein close to artery, at a difficult angle, loose skin
requiring traction and even probe pressure, or patient cooperation); and equipment
(needed a longer IV catheter, pushed button on IV catheter accidentally)
CONCLUSION: There are ongoing educational opportunities to improve
UGIVC placement first attempt success. However the high reported success rate and low
reported complication rate supports the ongoing use and tracking of this procedure.
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CONTENT OF CLINICAL INFORMATICS IN INTERNATIONAL TRAINING
STANDARDS FOR EMERGNECY MEDICINE SPECIALISTS
Holroyd B1, Beeson MS2, Hughes T3, Kurland L4, Sherbino J5, Truesdale M6, Hersh W7
1Department of Emergency Medicine, University of Alberta 2Department of Emergency Medicine, Northeast Ohio Medical University, Cleveland
OH, USA 3Emergency Medicine, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK 4Department of Medical Sciences, Örebro University, Sweden 5McMaster University, Hamilton ON 6Professor of Emergency Medicine, University of Melbourne, Melbourne, Australia 7Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science
University, Portland OR, USA
INTRODUCTION: The field of Clinical Informatics (CI) and specifically the
electronic health record, has been identified as a key facilitator to achieve a sustainable
evidence-based healthcare system for the future. International graduate medical education
programs have been challenged to ensure their trainees are provided with appropriate
skills to deliver effective and efficient healthcare in an evolving environment. This study
explored how international Emergency Medicine (EM) specialist training standards
address training in relevant areas of CI.
METHODS: A list of categories of CI competencies relative to EM was
developed following a thematic review of published references documenting CI
curriculum and competencies. Publicly available, published documents outlining core
content, curriculum and competencies from international organizations responsible for
specialty graduate medical education and/or credentialing in EM for the United States,
Canada, Australasia, the United Kingdom and Europe. These EM training standards were
reviewed to identify inclusion of topics related to the relevant categories of CI
competencies.
RESULTS: A total of 23 EM curriculum documents were included in the
thematic analysis. Curricula content related to critical appraisal/evidence-based medicine,
leadership, quality improvement and privacy/security were included in all EM curricula.
The CI topics related to fundamental computer skills, computerized provider order entry
and patient-centered informatics were only included in the EM curricula documents for
the United States and were absent for each other organization.
CONCLUSION: There is variation in the CI related content of the international
EM specialty training standards which were reviewed. Given the increasing importance
of CI in the future delivery of healthcare, organizations responsible for training and
credentialing specialist emergency physicians must ensure their training standards
incorporate relevant CI content, thus ensuring their trainees gain competence in essential
aspects of CI.
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CREATING A SUCCESSFUL EMERGENCY DEPARTMENT BASED
SUSTAINABLE MULTIDISCIPLINARY SIMULATION PROGRAM ACROSS
MULTIPLE SITES
Ma W, O’Dochartaigh, Mews L, Chan M, Brown T,
Alberta Health Services, Edmonton, Alberta.
INTRODUCTION: Multi-disciplinary, high fidelity, in-situ simulation can
create a realistic teaching environment that supports knowledge acquisition, improves
procedural skills, and enhances team communication. For ongoing quality improvement,
simulations were conducted across 11 emergency departments (ED) in the Edmonton
zone.
METHODS: In 2017, simulation sessions provided were doubled compared to
2016. Site needs assessment surveys were completed and cases created to address need.
Two separate half day adult and pediatric sessions were provided at each site, with three
separate cases and debrief between each. Facilitators included a nurse educator or
specialist, an emergency physician (adult or pediatric specialist), and simulation
technician. Following each simulation, a cross sectional, survey based assessment tool,
was given to each participant.
RESULTS: Pediatric and adult simulation attendance was 130 and 104
respectively. Clinical discipline attendance was: RN 107 (45.7%), MD 64 (27.4%) EMS
2 (0.9%), student RN 5 (2.1%), RT 14 (6%), not specified 21 (9%), observer 13 (5.6%),
CNE 4 (1.7%), LPN/Ortho tech 2 (0.9%), military med tech 1 (0.4%), Pharmacist 1
(0.4%). Overall mean results of feedback for Likert scale questions (1 strongly disagree
to 5 strongly agree) were: ‘scenario represented real life’ 4.6; “The crisis resource
management experience will be helpful” 4.5; “The knowledge gained will be helpful”
4.6; “learning environment was safe” 4.7; “able to suspend disbelief” 4.2; “The debrief
discussion was useful”; 4.7; “It achieved the learning objective” 4.6.
CONCLUSION: Simulation sessions were well attended and received in our
zone. 2018 plans include 50% more sessions, and continuing to focus on individual site
clinical needs.
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PROXIMAL EXTERNAL AORTIC COMPRESSION FOR LIFE-
THREATENING ABDOMINAL-PELVIC AND JUNCTIONAL HEMORRHAGE:
AN ULTRASONOGRAPHIC STUDY IN ADULT VOLUNTEERS.
Douma MJ1, ODochartaigh D, Picard C, Brindley P.
1Royal Alexandra Hospital 1University College Dublin
INTRODUCTION: Following life-threatening abdominal-pelvic (and junctional)
penetrating trauma, the goal is to limit blood-loss while expediting operative rescue.
Unfortunately, junctional hemorrhage is often not amenable to direct compression and
few temporizing strategies are available beyond dressings, hypotensive resuscitation, and
transfusion.
METHODS: A convenience sample of six pairs of male paramedic volunteers
were recruited from a trauma life-support course. Inclusion criteria were: age under 26
and in good physical health. Strict exclusion criteria were used to ensure minimal risk of
atherosclerotic plaque detachment. In six randomized pairs, participants alternated
learning and performing the maneuver on each other. Blood-flow was measured in
recipients before, during and after compression by pulse wave Doppler ultrasound.
Compression was maintained until i) blood flow was arrested for ten seconds, or ii) thirty
seconds elapsed. The primary outcome was cessation of femoral arterial blood-flow as
assessed by pulse wave Doppler ultrasound at the right femoral artery. Secondary
outcomes were maximum discomfort using a visual analog scale (VAS) and negative
sequelae within seven days of participation.
RESULTS: Aortic blood flow was arrested in 12 volunteers. Mean time to
cessation was 14 seconds. Mean discomfort was five out of ten. No complications or
negative sequelae were reported. Aortic blood flow was arrested in all 12 volunteers.
Mean time to blood flow cessation was 14 seconds on average (range nine to 19 seconds).
Mean discomfort was five out of ten, (range four to seven). No complications were
reported at the 15 minute, 24-hour and 168-hour reassessments.
CONCLUSION: Despite noteworthy limitations, our data suggests it is
reasonable to attempt to temporize major abdominal-pelvic and junctional haemorrhage
using bimanual PEAC. In the absence of immediate alternatives there appear to be few
downsides to pre-hospital PEAC, and while concomitantly expediting definite care.
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VALIDATION OF THE STOPLIGHT PAIN SCALE TOOL IN THE CANADIAN
EMERGENCY SETTING
Ali S, Shwetz S, Morrison E, Drendel AL, Rajagopal M, Yaskina M, Estey A.
Department of Pediatrics, University of Alberta, Edmonton, Alberta
INTRODUCTION: A variety of pain assessment tools exist for children, however
none of the current scales were created specifically for family use. Further, none provide
direct guidance with regards to pain treatment threshold. This study aimed to validate a
novel, three faced, coloured coded, family-friendly pain tool, the Stoplight Pain Scale.
METHODS: A prospective observational cohort study was conducted at the
Stollery Children’s Hospital emergency department (ED) from November 2014 to
February 2017. Patients (3-12 years) and their caregivers were asked to rate their pain
using the novel Stoplight Pain Scale as well as the Faces Pain Scale-Revised (FPS-R).
Pain was measured at presentation to the ED, immediately following painful procedures,
and thirty minutes after analgesia administration.
RESULTS: A purposeful random sample of 227 patients were included; 61/227
(26.9%) of patients were 3-5 years old and 166/227 (73.1%) were 6-12 years old.
Correlation between the two pain scales was consistently ‘fair’ to ‘moderate’; using Kappa
Statistics, a baseline correlation for Stoplight and FPS-R was ‘fair’ for both caregivers
(0.38, 95% CI 0.28 – 0.48) and patients (0.36 95% CI 0.27-0.45). The Stoplight Pain Scale
had ‘fair to moderate’ correlation between caregiver and patient scores, (0.37, 95% CI 0.27-
0.47), compared to FPS-R which showed ‘poor to fair’ agreement between caregiver and
child scores (0.20, 95% CI 0.12-0.29). Regardless of age or hospitalization status, 64% of
patients (139/218) and 54% caregivers (118/220) preferred the Stoplight Pain scale
(p=0.001).
CONCLUSION: The Stoplight Pain Scale correlates moderately well with FPS-
R, a validated pain assessment tool for children and shows good correlation between
patients’ and caregivers’ assessment of reported pain. The Stoplight Pain Scale is a simple,
easy to administer tool that may have a role in empowering family involvement in ED pain
management. Future research should focus on at-home study of the tool.
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THE REVISED METRIQ SCORE: AN INTERNATIONAL USABILITY
ANALYSIS OF A QUALITY EVALUATION INSTRUMENT FOR MEDICAL
EDUCATION BLOGS
Colmers-Gray I1, Krishnan K, Chan TM, Trueger NS, Paddock M, Grock A, Zaver F,
Thoma B
1Department of Emergency Medicine, University of Alberta, Edmonton, Alberta.
INTRODUCTION: With the proliferation of medical education blogs, methods
of measuring quality are becoming more critical. The Medical Education Translational
Resources: Impact and Quality (METRIQ) Study rated the quality of blogs using the
METRIQ-8 Score. This score demonstrated poor reliability. Our goal was to analyze user
feedback on this tool and use this to guide creation of a more clear and user-friendly
revised METRIQ (rMETRIQ) Score.
METHODS: The evidence-based 8-item METRIQ-8 Score was previously
derived using a systematic review, qualitative analysis, two Delphi studies and a
derivation study. In the METRIQ study, participants rated the quality of 15 EM-related
blog posts using the METRIQ-8 Score. Participants used a 7-point scale (1=best) and
comments to evaluate the METRIQ-8 Score on the clarity of specific elements. Usability
ratings were summarized using mean scores and % of participants rating an item unclear.
Comments underwent qualitative thematic analyses. Qualitative feedback guided the
development of the rMETRIQ Score.
RESULTS: 309 EM attendings, residents and medical students completed the
study. Global ratings were good overall for ease of use (mean 2.7±1.3). Participants
reported positively on the score’s structure, systematic nature, and straightforwardness.
Overall, they found it useful for guiding learners and blog creators. Q2 (review
processes), Q4 (editorial processes), Q5 (reference consistency), and Q7 (learner
interactions) were marked unclear by >10% of participants. Qualitative analysis of
comments identified areas for improvement. The following major changes were made:
scoring scale was shortened to 4 points per question; specific anchors were developed to
score each question; ambiguous terminology was clarified; and questions were grouped
into 3 thematic categories. Due to overlap, Q2 and Q4 were combined, as were Q3
(reference citation) and Q5. A new question was added to evaluate writing and
formatting.
CONCLUSION: A robust usability analysis of feedback on the METRIQ-8
Score highlighted areas for improvement and led to the more user-friendly rMETRIQ
Score. Though it requires validation, the rMETRIQ Score has improved clarity and thus
reliability among untrained raters. We hope this score will serve as a quality benchmark
for blog users and producers.
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DEVELOPMENT AND IMPLEMENTATION OF A WORKSHOP FOR
ADVANCED CARE PLANNING AND GOALS OF CARE CONVERSATIONS IN
THE EMERGENCY DEPARTMENT Fletcher C1, Brisebois A, Gauri A, Ha D
1Department of Emergency Medicine, University of Alberta, Edmonton, Alberta.
INTRODUCTION: Advanced care planning (ACP) and Goals of Care (GOC)
discussions are becoming increasingly common in our emergency departments (ED). The
national ACP task group has found that the majority of Canadians have not had prior
ACP/GOC discussions, nor have they obtained proper documentation of their wishes.
The task of having these difficult but important conversations falls frequently to the ED.
Despite this, our emergency medicine (EM) residents receive little formal training in
ACP discussions. To address this need, we developed and implemented a workshop in
ACP/GOC conversations for the University of Alberta EM academic curriculum.
METHODS: A literature search was performed to identify best practices for ACP
discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients
appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked
to identify previous difficult ACP discussions and highlight aspects of these cases that
were challenging in the ED environment. These experiences, best practices and published
APC curricula informed the development of a 3-hour case-based workshop that was
implemented in the 2016/17 academic year for EM staff and residents.
RESULTS: Cases utilized in the workshop emphasized common ACP/GOC
situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC
whose family did not accept the GOC designation. Case 2: A 72 year old with multiple
comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with
decreased LOC whose family asks for an ACP discussion in the ED. Participants were
divided into groups (5-6 members). Each small group analyzed and discussed each case
before the participants reconvened and discussed their opinions in one large group. ACP
experts from palliative care, emergency medical services and EM facilitated the
discussions highlighting the best practices from the literature for each case reviewed. Pre
and post Likert surveys were distributed to workshop participants to assess changes in
confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically
significant improvement in learner confidence within the following areas (N=21;
P<0.05): identifying patients appropriate for GOC discussions, initiating GOC
discussions, and identifying barriers to GOC, in the ED. The majority (89%) of
participants agreed the workshops should become part of our academic curriculum.
CONCLUSION: An ACP/GOC workshop was successfully implemented and
further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead,
we will look at using other teaching modalities such as simulation to further enhance the
delivery of the curriculum. We will also attempt to capture defined physician behaviors
(e.g. documenting GOC in the ED chart, sending letters to family physicians
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33
documenting GOC discussions) to gauge uptake of the workshop principles into clinical
practice.
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34
PREDICTORS OF ADMISSION IN UNSCHEDULED RETURN VISITS TO THE
EMERGENCY DEPARTMENT
Hayward J1, Hagtvedt R, Ma W, Gauri A, Vester M, Holroyd BR
Department of Emergency Medicine, University of Alberta, Edmonton, Alberta.
INTRODUCTION: The 72-hr unscheduled return visit (URV) of an emergency
department (ED) patient is often used as a key performance indicator in Emergency
Medicine. Patients with unscheduled return visits and admission to hospital (URVA) may
represent a distinct subgroup of URVs compared to unscheduled return visits with no
admission (URVNA).
METHODS: A retrospective cohort study of all 72-hr URVs in adults across nine
EDs in the Edmonton Zone (EZ) over a one-year period (Jan 1 2015 – Dec 31 2015) was
performed using ED information system data. URVA and URVNA populations were
compared and a multivariable analysis identified predictors of URVA.
RESULTS: Analysis of 40,870 total URV records, including 3,363 URVAs,
revealed predictors of URVA on the index visit including older age (>65 yrs, OR 3.6),
fewer annual ED visits (<4 visits, OR 2.0), higher disease acuity (CTAS 2, OR 2.6),
gastrointestinal presenting complaint (OR 2.2), presenting to a large referral hospital (OR
1.4), and more hours spent in the ED (>12 hours, OR 2.0). A decrease in CTAS score
(increase in disease acuity) upon return visit was also a risk factor (-1 CTAS level, OR
2.6). ED crowding at the index visit, as indicated by occupancy level, was not a
predictor.
CONCLUSION: We demonstrate that URVA patients comprise a distinct
subgroup of 72-hr URVs across an entire health region. Risk factors for URVA are
present at the index visit suggesting that patients at high risk for URVA may be
identifiable prior to admission.